Would patients be able to see any physician they wanted?
Each individual would select a primary-care physician in a particular group. That group would have non-exclusive relationships with specialists of their choice. Normally, patients would need a referral to see a specialist, but there would be exceptions: for example, somebody with a serious, chronic condition could see a specialist regularly for that condition after an initial referral, and women would be able to see an ob/gyn without a referral. But those specialists would be expected to stay in close touch with the patient’s primary care doctor. Also, patients could go directly to a specialist for an additional copayment, with the same caveat. If patients didn’t like the specialists affiliated with a particular group, they could switch groups at specified intervals. And if they didn’t like their primary-care doctor, they could switch to a different physician within the same group.
How would care be coordinated?
The primary-care group would function similarly to the “medical home” that some medical societies favor. With the support of the group, the primary-care physician would do as much as he or she could for each patient, and would also coordinate all of the patient’s ambulatory care across other care settings. In the hospital, another primary-care physician known as a “hospitalist” would coordinate the patient’s care and the handoff back to the outpatient setting. Hospitalists are already common in the U.S., but they don’t always coordinate care well. In this model, they’d all work for the hospitals, rather than outside groups or companies, and they’d be expected to stay in close touch with the office-based physicians.
With primary-care doctors in short supply, where would we find enough physicians to make this system work?
In the United States, roughly a third of physicians are primary-care doctors, and that number is declining as young doctors increasingly go into specialties that are more lucrative than primary care. In contrast, the ratio between primary-care physicians and specialists in most other advanced countries is close to 50/50. That would be our goal, as well. In the long run, the changed relationship between primary-care physicians and specialists under this model would lead to increased income for the former and decreased earnings for the latter. As a result, more physicians would go into primary care. But it would take a decade or more to fully right the balance. In the meantime, groups would have to rely on nurse practitioners, physician assistants, and lower-level clinicians to help doctors tend to patients’ needs and coordinate their care.
How would you apply the administrative cost savings under your model to cover the uninsured?
This model would eliminate about 10 percent of private insurance costs, and 5 to 7 percent of administrative costs for providers. The government would require the utility insurers to build the administrative savings on the insurance side into their premiums. So the currently insured would continue to pay that extra amount, which the government would use to cover the uninsured. Some of the savings on the provider side would be recaptured through lower physician group budgets, and the hospital prices set jointly by the government and utility insurers would take into account the hospitals’ decreased administrative costs.
Under your model, there would be a standard benefit package for the entire country. But people in some areas are much better able to afford these benefits than those in other regions. How would you ensure that these benefits were available to everyone?
The IRS would collect health care contributions from employers, employees, the self-employed and the unemployed, all in proportion to their means. These contributions, similar to insurance premiums, would be based on the annual costs of care in a particular insurance region, including the budgets set by local physician groups. However, nobody would have to pay more than a set portion of their income for health insurance, and no company would have to pay more than a set percentage of its payroll. The poor would pay nothing at all. To the extent that the sum of health care contributions in a particular area fell short of the utility insurer’s total budget for care, the federal government could make up the difference out of general tax revenues.
